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Background South Africa has a high and rising prevalence of hypertension. Many affected individuals are not using medication, and few have controlled blood pressure. Until recently, primary care clinics focused on maternal and child health and management of acute conditions, but new government initiatives have shifted the focus to chronic diseases, including HIV/AIDS and hypertension. Methods/Design The Nkateko trial will test the effectiveness of clinic-based lay health workers (LHWs) in supporting hypertension management. It is a pragmatic, cluster randomised controlled trial based in the Agincourt subdistrict of northeast South Africa, and it is underpinned by longterm health and demographic surveillance. Eight primary care facilities, with their catchment communities, are randomised to usual care or the addition of LHWs focused on chronic care. All clinics (intervention and control) will be provided with a clerk to collect information on clinic attendees and will match them to preexisting surveillance records. Intervention clinics will have LHWs working alongside nursing staff and focusing on health care for people with chronic conditions, particularly hypertension. The LHWs will be supported by an implementation manager, who will work with clinic staff to develop the most effective role for the LHWs. Control clinics will continue to provide usual care. The primary outcome will be the change between two population surveys conducted before and after the intervention in the proportion of the population with uncontrolled hypertension and a risk profile indicating at least moderate risk of cardiovascular disease. A process evaluation will be based on a realist approach using patient exit interviews, clinic observations and interviews with health professionals, LHWs and patients to document the intervention and its implementation. Discussion There are challenges in the design of this trial. Assessing change through population surveys may reduce measurable effects; however, we feel this is appropriate because we aim to attract those who currently do not use clinics, and we hope to improve care for clinic users. Clinics were randomised at an open meeting because we were concerned that a remote process of randomisation would not be trusted by the community. We are constantly working to achieve an effective balance between the intervention and process evaluations. [ABSTRACT FROM AUTHOR]

Whilst progress has been made, evidence of effective approaches to improve action on addressing the social and structural drivers of the HIV epidemic remains a priority, to meet the 2030 sustainable development agenda, and to achieve key HIV targets, including the 90-90-90 target and the Treatment as Prevention (TasP) intervention. With a focus on the public sector in South Africa, we critically reflect on the HIV mainstreaming approach, assessing its ability to augment multisectoral action on the response to HIV. We reflect on progress made in mainstreaming HIV in non-health sector departments, exploring factors that have enabled and hindered the process. We also highlight limitations in the adopted approach to mainstreaming HIV in non-health sector departments in South Africa; which currently promotes working in silos and does not encourage collaboration and partnerships. We propose a three-step approach to effective mainstreaming of HIV that will augment multisectoral action. The approach also contributes towards realising the sustainable development agenda of "leaving no one behind" and achieving the national and global targets on HIV that are embedded in collaborative efforts. [ABSTRACT FROM AUTHOR]

Background: The mental and financial strain linked to unpaid caregiving has been amplified during the COVID-19 pandemic. In sub-Saharan Africa, carers of adolescents living with HIV (ALHIV) are critical for maintenance of optimum HIV treatment outcomes. However, the ability of caregivers to provide quality care to ALHIV is undermined by their ability to maintain their own wellbeing due to multiple factors (viz. poverty, stigma, lack of access to social support services) which have been exacerbated by the COVID-19 pandemic. Economic incentives, such as cash incentives combined with SMS reminders, have been shown to improve wellbeing. However, there is a lack of preliminary evidence on the potential of economic incentives to promote caregiver wellbeing in this setting, particularly in the context of a pandemic. This protocol outlines the design of a parallel-group pilot randomised trial comparing the feasibility and preliminary effectiveness of an economic incentive package versus a control for improving caregiver wellbeing. Methods: Caregivers of ALHIV will be recruited from public-sector HIV clinics in the south of the eThekwini municipality, KwaZulu-Natal, South Africa. Participants will be randomly assigned to one of the following groups: (i) the intervention group (n = 50) will receive three cash payments (of ZAR 350, approximately 23 USD), coupled with a positive wellbeing message over a 3-month period; (ii) the control group (n = 50) will receive a standard message encouraging linkage to health services. Participants will be interviewed at baseline and at endline (12 weeks) to collect socio-demographic, food insecurity, health status, mental health (stigma, depressive symptoms) and wellbeing data. The primary outcome measure, caregiver wellbeing, will be measured using the CarerQoL instrument. A qualitative study will be conducted alongside the main trial to understand participant views on participation in the trial and their feedback on study activities. Discussion: This study will provide scientific direction for the design of a larger randomised controlled trial exploring the effects of an economic incentive for improving caregiver wellbeing. The feasibility of conducting study activities and delivering the intervention remotely in the context of a pandemic will also be provided. Trial registration: PACTR202203585402090. Registry name: Pan African Clinical Trials Registry (PACTR); URL: https://pactr.samrc.ac.za/; Registration. date: 24 March 2022 (retrospectively registered); Date first participant enrolled: 03 November 2021 [ABSTRACT FROM AUTHOR]

Antiretroviral treatment requires high levels of adherence to be effective. This qualitative study explores the reasons for poor adherence among 22 purposively selected poor urban participants in South Africa. Over a 4-month period in 2009, we prospectively investigated experiences of HIV diagnosis and treatment, adherence, and withdrawal from treatment. Patients with no stable food sources faced significant barriers in adhering to treatment regimens and staying sufficiently healthy to search for, obtain or retain a job. The narratives also identify the influence on adherence of self-esteem and social support, vulnerability generated by ill health, gendered conflict, social inequities amplified by HIV, and exhaustion due to the social burden of the epidemic. Multi-dimensional, inter-sectoral programs that tackle the social determinants of health, such as food insecurity, poverty, gendered inequities, and treatment adherence are more likely to be successful, than single interventions to support adherence. [ABSTRACT FROM AUTHOR]

Background: Increased demand for healthcare services in countries experiencing high HIV disease burden and often coupled with a shortage of health workers, has necessitated task shifting from professional health workers to Lay Health Workers (LHWs) in order to improve healthcare delivery. Maternal and Child Health (MCH) services particularly benefit from task-shifting to LHWs or similar cadres. However, evidence on the roles and usefulness of LHWs in MCH service delivery in Sub-Saharan Africa (SSA) is not fully known. Objectives: To examine evidence of the roles and impact of lay health worker programmes focusing on Women Living with HIV (WLH) and their HIV-exposed infants (HEIs). Methods: A scoping review approach based on Arksey and O’Malley’s guiding principles was used to retrieve, review and analyse existing literature. We searched for articles published between January 2008 and July 2018 in seven (7) databases, including: MEDLINE, Embase, PsycINFO, Joanna Briggs, The Cochrane Library, EBM reviews and Web of Science. The critical constructs used for the literature search were “lay health worker”, “community health worker”, “peer mentor”, “mentor mother,” “Maternal and Child health worker”, “HIV positive mothers”, “HIV exposed infants” and PMTCT. Results: Thirty-three (33) full-text articles meeting the eligibility criteria were identified and included in the final analysis. Most (n = 13, 39.4%) of the included studies were conducted in South Africa and used a cluster RCT design (n = 13, 39.4%). The most commonly performed roles of LHWs in HIV specific MCH programmes included: community engagement and sensitisation, psychosocial support, linkage to care, encouraging women to bring their infants back for HIV testing and supporting default tracing. Community awareness on Mother to Child Transmission of HIV (MTCT), proper and consistent use of condoms, clinic attendance and timely HIV testing of HEIs, as well as retention in care for infected persons, have all improved because of LHW programmes. Conclusion: LHWs play significant roles in the management of WLH and their HEIs, improving MCH outcomes in the process. LHW interventions are beneficial in increasing access to PMTCT services and reducing MTCT of HIV, though their impact on improving adherence to ART remains scanty. Further research is needed to evaluate ART adherence in LHW interventions targeted at WLH. LHW programmes can be enhanced by increasing supportive supervision and remuneration of LHWs. [ABSTRACT FROM AUTHOR]

Without strengthened health systems, significant access to antiretroviral (ARV) therapy in many developing countries is unlikely to be achieved. This paper reflects on systemic challenges to scaling up ARV access in countries with both massive epidemics and weak health systems. It draws on the authors' experience in southern Africa and the World Health Organization's framework on health system performance. Whilst acknowledging the still significant gap in financing, the paper focuses on the challenges of reorienting service delivery towards chronic disease care and the human resource crisis in health systems. Inadequate supply, poor distribution, low remuneration and accelerated migration of skilled health workers are increasingly regarded as key systems constraints to scaling up of HIV treatment. Problems, however, go beyond the issue of numbers to include productivity and cultures of service delivery. As more countries receive funds for antiretroviral access programmes, strong national stewardship of these programmes becomes increasingly necessary. The paper proposes a set of short- and long-term stewardship tasks, which include resisting the verticalisation of HIV treatment, the evaluation of community health workers and their potential role in HIV treatment access, international action on the brain drain, and greater investment in national human resource functions of planning, production, remuneration and management. Seul un renforcement des systèmes de santé permettra à nombre de pays en développement de garantir un large accès à la thérapie antirétrovirale. Cet article réfléchit aux obstacles systémiques contrariant l'accès aux ARV dans des pays où l'épidémie est massive et les systèmes de santé faibles. Il est fondé sur l'expérience des auteurs en Afrique australe et sur le cadre de l'OMS pour l'évaluation de la performance des systèmes de santé. Tout en constatant la persistance des manques financiers, l'article se concentre sur la réorientation des services vers le traitement des maladies chroniques et la crise des ressources humaines dans les systèmes de santé. Des facteurs comme la pénurie de personnel, la distribution inégale, la faible rémunération et la migration accélérée des agents de santé qualifiés sont de plus en plus considérés comme des obstacles systémiques clés à l'élargissement du traitement du VIH. Néanmoins, les problèmes dépassent la question de l'offre pour inclure la productivité et les cultures de la prestation des services. À mesure que davantage de pays reçoivent des fonds pour les programmes d'accès aux antirétroviraux, un fort encadrement national de ces programmes devient de plus en plus nécessaire. L'article propose un ensemble de tâches de supervision à court et long terme, notamment s'opposer à la verticalisation du traitement du VIH, évaluer les agents de santé communautaires et leur rôle potentiel dans l'accès au traitement du VIH, mener une action internationale sur l'exode des cadres et investir davantage dans les fonctions nationales des ressources humaines en matière de planification, production, rémunération et gestion. En muchos países en desarrollo, es improbable que se logre mayor acceso a la terapia antirretroviral (ARV) sin antes fortalecer los sistemas de salud. En este artículo, basado en la experiencia de los autores en África meridional y en el marco de la Organización Mundial de la Salud sobre el desempeño de los sistemas sanitarios, se reflexiona sobre los retos sistémicos relacionados con la ampliación del acceso a los ARV en los países con grandes epidemias y sistemas de salud deficientes. Aunque se reconoce la brecha aún considerable en financiamiento, se destacan los retos en reorientar la prestación de servicios hacia el tratamiento de enfermedades crónicas y la crisis de recursos humanos en los sistemas de salud. El suministro inadecuado, la deficiente distribución, la baja remuneración y la acelerada migración de los trabajadores sanitarios calificados, son considerados cada vez más como limitaciones clave de los sistemas en la ampliación del tratamiento del VIH. Otos problemas son la productividad y las culturas de prestación de servicios. A medida que más países reciben fondos para los programas de acceso a los ARV, también aumenta la necesidad de contar con una sólida administración nacional de esos programas. En este artículo se propone una serie de tareas administrativas de corto y largo plazo: resistencia a la verticalización del tratamiento del VIH, evaluación de los trabajadores de la salud comunitarios y su posible función en ampliar el acceso al tratamiento del VIH, acción internacional respecto al éxodo de profesionales y una mayor inversión en las funciones de planificación, producción, remuneración y administración de los recursos humanos nacionales. [ABSTRACT FROM AUTHOR]